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Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Glob Health . 2026 Apr 15;11(4):e020872. doi: 10.1136/bmjgh-2025-020872 Search in PMC Search in PubMed View in NLM Catalog Add to search Bringing severe non-communicable disease care to district-level hospitals in Nepal: PEN-Plus experience and regional policy implications Sandeepa Karki Sandeepa Karki 1 Kathmandu Institute of Child Health, Budhanilkantha, Kathmandu, Nepal Find articles by Sandeepa Karki 1 , Shishir Paudel Shishir Paudel 1 Kathmandu Institute of Child Health, Budhanilkantha, Kathmandu, Nepal 2 National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory, Australia Find articles by Shishir Paudel 1, 2, ✉ , Dhurba Khatri Dhurba Khatri 1 Kathmandu Institute of Child Health, Budhanilkantha, Kathmandu, Nepal Find articles by Dhurba Khatri 1 , Yamuna Chhetri Yamuna Chhetri 1 Kathmandu Institute of Child Health, Budhanilkantha, Kathmandu, Nepal Find articles by Yamuna Chhetri 1 , Bhagawan Koirala Bhagawan Koirala 1 Kathmandu Institute of Child Health, Budhanilkantha, Kathmandu, Nepal Find articles by Bhagawan Koirala 1 Author information Article notes Copyright and License information 1 Kathmandu Institute of Child Health, Budhanilkantha, Kathmandu, Nepal 2 National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory, Australia ✉ Shishir Paudel; [email protected] The authors are affiliated with the Kathmandu Institute of Child Health, which is the implementing partner of the PEN-Plus project in Nepal. The authors declare no competing interests. Received 2025 Jun 10; Accepted 2026 Mar 20; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13084865 PMID: 41986056 Abstract Severe non-communicable diseases (NCDs) such as type 1 diabetes mellitus (T1DM), sickle cell disease (SCD), thalassaemia and congenital heart conditions are prevalent in low-resource settings but remain largely unaddressed in the primary care system. Nepal’s Package of Essential NCD Interventions-Plus (PEN-Plus) initiative demonstrates how peripheral provincial hospitals (former district hospitals) can effectively deliver decentralised, equitable care for childhood-originated NCDs such as T1DM, SCD, thalassaemia, rheumatic and congenital heart diseases, epilepsy and childhood asthma. Led by the Ministry of Health and Population, Epidemiology and Disease Control Division in partnership with key stakeholders, the programme has been implemented in six districts of Nepal, offering early diagnosis, treatment, social protection and follow-up care. Early implementation demonstrates feasibility, with 3278 patients receiving care through PEN-Plus clinics over 2 years using modest investments and existing district hospital resources. Scalability is supported by the expansion from two to six districts and by government policy commitments, including provincial budget allocations for further rollout. This paper presents an overview of the PEN-Plus programme in Nepal, its design, implementation and early outcomes, illustrating how this approach offers a scalable solution for severe NCD care in resource-constrained settings. The PEN-Plus model provides critical policy insights and valuable lessons for other South Asian countries and low- and middle-income countries seeking to strengthen equitable NCD care through decentralised health systems. Keywords: Nepal, Global Health, Health policies and all other topics, Child health, Health policy Summary box. PEN-Plus brings specialised care for severe non-communicable diseases (NCDs) to peripheral provincial hospitals in Nepal, improving access for underserved and rural populations. The programme integrates clinical services with social protection, capacity building and policy alignment to ensure equity and sustainability. Early implementation across six districts shows the feasibility and scalability of care for severe NCDs among children and adolescents. Nepal’s experience offers a replicable model for low-resource countries aiming to decentralise complex NCD care through health system strengthening. Introduction Globally, NCDs are a leading cause of morbidity and mortality, with low- and middle-income countries (LMICs) like Nepal bearing a disproportionate burden. 1 2 An estimated 74% of all global deaths are due to NCDs, with 73% of these occurring in LMICs. 1 The perception that NCDs mainly affect adults contributes to under-recognition of their increasing burden among children and adolescents, where consequences are more severe, long-lasting and financially demanding for families and the health system. 3 Severe NCDs such as type 1 diabetes mellitus (T1DM), sickle cell disease (SCD), thalassaemia, rheumatic heart diseases (RHD), congenital heart diseases (CHD), childhood cancers and neurodevelopmental disorders demand continuous, specialised care. 4 However, such services remain scarce in resource-constrained settings, including Nepal’s local and provincial healthcare systems. 5 WHO estimates that over 70% of deaths in Nepal are due to NCDs, with rising incidence among younger adults (18–30 years). 6 The WHO STEPwise approach to NCD risk factor surveillance (STEPS) survey 2019 reported 24.5% of individuals aged 15–69 years in Nepal have hypertension, diabetes or raised cholesterol levels. 7 Though national childhood NCD data are scarce, a study from 15 tertiary hospitals showed that NCDs and injuries are common among children and adolescents, indicating the need to strengthen systems for early prevention and management of childhood NCDs. 8 Nepal adopted the WHO’s Package of Essential NCD Interventions (WHO-PEN) in October 2016 to strengthen the integration of basic NCD services at primary healthcare settings. 9 , 11 However, WHO-PEN primarily targets only NCDs like hypertension, chronic obstructive pulmonary disease and type 2 diabetes and does not address other severe and complex conditions. 10 Consequently, patients with severe NCDs often seek care at overcrowded tertiary hospitals, increasing strain on both patients and the overall system. 12 In Nepal, the PEN-Plus initiative was introduced in 2021 through a partnership between the Ministry of Health and Population (MoHP) and the Kathmandu Institute of Child Health (KIOCH), with financial support from the NCDI Poverty Network secretariat at the Centre for Integration Science, Brigham and Women’s Hospital, to address the service gap. 13 This initiative decentralises severe NCD care to peripheral hospitals to improve access and equity. 14 This paper evaluates the design, implementation and policy implications of PEN-Plus in Nepal using programme data, stakeholder consultations and policy documents. A retrospective review of all patient records from PEN-Plus clinics across six hospitals was conducted, covering the period from the programme’s formal initiation in January 2023 to May 2025. Iterative consultations were conducted with key stakeholders, including clinical staff (medical officers, nurses and paramedics), programme implementers and government personnel from the MoHP, particularly those from the Epidemiology and Disease Control Division (EDCD). These consultations involved field visits to PEN-Plus sites and structured discussions to capture implementation experiences, operational challenges and policy priorities. Patient records were anonymised and reviewed as part of routine PEN-Plus monitoring. Data cleaning involved routine checks integrated into the PEN-Plus monitoring system, including validation of patient enrolment, diagnostic codes and follow-up status by district data focal persons. These quality checks are part of standard PEN-Plus reporting procedures. Informal patient feedback was collected anonymously with consent during clinic visits. The continuous and multistakeholder engagement ensured diverse perspectives, though specific participant numbers were not quantified due to the ongoing and dynamic consultation process. PEN-plus implementation status in Nepal The Lancet Commission on NCDs and Injuries for the Poorest Billion identified PEN-Plus as a promising integrated, team-based care model for managing severe NCDs in low-resource settings. 15 It was formalised by the WHO Regional Office for Africa in 2022 during its 72nd Regional Committee Meeting, following a 2019 consultation to develop the strategy. 16 The model is flexible and adaptable, allowing countries to tailor priorities to local disease burdens. 4 17 Nepal’s implementation of PEN-Plus marks a milestone in decentralising severe NCD care. 12 The programme is led by EDCD, 18 with support from partners including KIOCH, 14 UNICEF 19 and the NCDI Poverty Network. 20 Initially piloted in two districts (Bardiya and Jhapa) as a service site and one district (Dolakha) as a training site, the clinic has been expanded to four additional sites in Siraha, Dailekh, Bajhang and Gulmi districts with financial support from UNICEF Nepal, bringing the total to six hospitals. 14 21 In Nepal, the model is adapted to local needs and implemented through selected peripheral provincial hospitals, designated as hubs for specialised NCD services. These facilities include hospitals previously known as District Hospitals, now operating under provincial health systems but still functioning as main service points for district populations. These hospitals previously offered only basic NCD care, 22 as they do not have adequate essential diagnostic and monitoring capacities such as echocardiography, glycated haemoglobin (HbA1c) testing, arterial blood gas analysis and high-performance liquid chromatography. Patients with suspected severe NCDs were therefore referred directly to tertiary hospitals. With PEN-Plus, these sites have been equipped with key diagnostic technologies, trained staff and condition-specific care pathways, enabling comprehensive diagnosis, treatment, follow-up and referral for severe NCDs at the peripheral level. 14 A structured referral and counter-referral system integrates primary, secondary and tertiary levels of care, 12 helping to reduce overreliance on urban tertiary centres and bringing advanced services closer to underserved communities. PEN-Plus strengthens health system capacity through workforce training, infrastructure upgrades and supply chain improvements. It incorporates patient-centred strategies, including social protection and community engagement, to promote equity and sustainability. The clinics are embedded in government-run hospitals, leveraging existing infrastructure while enhancing capacity via dedicated units. A structured referral mechanism ensures patients receive appropriate care at the district level and are referred to tertiary centres only when necessary. 23 PEN-Plus implementation in Nepal is guided by eight foundational components ( figure 1 ), which ensure each site is equipped with the necessary infrastructure, trained personnel, essential medicines, health information systems and social support mechanisms to deliver high-quality care for complex NCDs. These components also serve as a framework for monitoring progress and guiding future scale-up. Figure 1. Foundational components of the PEN-Plus programme in Nepal. Open in a new tab Government leadership and policy integration Strong government leadership has been central to the successful launch and expansion of PEN-Plus in Nepal. The MoHP leads the initiative, reflecting its commitment to address the growing burden of NCDs. Strategic oversight is provided by the PEN-Plus Steering Committee, chaired by the MoHP Secretary, and the Coordination Committee is led by the Director General of the Department of Health Services, while operational coordination is led by EDCD through a Technical Working Committee, which collaborates with key partners. 14 This governance structure ensures streamlined decision-making and coordinated implementation. At the implementation level, peripheral provincial hospitals host PEN-Plus clinics under the supervision of medical superintendents, embedding services within existing public health infrastructure. The programme aligns with national policies, including the Multisectoral Action Plan for Prevention and Control of NCDs (2021–2025), 24 the National Health Policy 2019, 25 15th 5-year development plan (2019–2024), 26 the Nepal Health Sector Strategic Plan 2022–2030, 27 the Basic Health Service Package 28 and the National Health Insurance Programme, 29 ensuring a strong policy framework for effective implementation. These alignments ensure the PEN-Plus is not an isolated initiative but an integrated part of Nepal’s healthcare system. However, sustained policy integration requires formal incorporation of PEN-Plus indicators into national monitoring frameworks and development of district-level performance targets. Policies around health workforce deployment and supply chain financing must be updated to institutionalise the programme beyond donor dependency. Service delivery package PEN-Plus in Nepal targets high-priority severe NCDs, including T1DM, RHD, CHD, haemoglobinopathies (SCD and thalassaemia), childhood cancers, severe asthma and neurodevelopmental disorders (including autism, attention deficit hyperactivity disorder and epilepsy). 12 As of May 2025, six hospitals function as PEN-Plus centres, collectively providing care to 3278 patients with severe NCDs ( figure 2 ), of whom 603 (18.4%) are under 19, underscoring the programme’s importance for early-onset NCDs. Implementation has led to increased identification of conditions such as thalassaemia, RHD, CHD and T1DM at peripheral hospitals, 13 demonstrating improved diagnostic reach. Figure 2. Number of patients enrolled at PEN-Plus sites from January 2023 to May 2025. AF, atrial fibrillation; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; HTN, hypertension; MI, myocardial infarction; NCD, non-communicable disease; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus. Open in a new tab The model complements the existing WHO-PEN by offering more advanced, long-term care for patients with complex needs. 23 Each site follows standardised protocols, enrols patients based on eligibility criteria, facilitates regular follow-up for treatment monitoring and adjustment, and ensures that patients with severe NCDs are not overlooked. Patients enrolled in PEN-Plus clinics are monitored through regular follow-ups, and those who miss their scheduled appointments are proactively contacted and recalled for care. PEN-Plus has also emphasised the importance of counselling for these severe NCDs (in terms of lifestyle, medication, device use and complications) to foster behavioural change, increase medical adherence and enhance patient compliance with treatment. To reduce chronic care costs, PEN-Plus integrates social protection mechanisms into its service delivery model. Underserved patients are identified through a ward-level recommendation letter verifying poverty status, and when needed, the PEN-Plus team conducts household socioeconomic assessments to confirm vulnerability. These underserved patients receive free diagnostics, medications and consultations. For individuals who require referral to tertiary centres but cannot afford travel costs, the programme also covers transportation and accommodation expenses. The programme covers premium costs required for registration in Nepal’s National Health Insurance Scheme 29 for patients who cannot afford it. This expenditure is financed through PEN-Plus with support from development partners. By integrating clinical and socioeconomic support, the PEN-Plus model enhances access, improves adherence and contributes to better health outcomes for the patients. Capacity building of human resources A component healthcare workforce is a cornerstone of an effective healthcare system, 30 including PEN-Plus services. Recognising the complexity of severe NCD care, the programme prioritised capacity building for district-level medical officers, nurses and paramedics. 15 They are trained to diagnose, manage and follow up on a range of life-threatening NCDs previously handled only in tertiary hospitals. To support this, a structured framework was developed with tailored training workshops, on-the-job mentorship and refresher courses, adapted to each hospital’s clinical needs. Training efforts are further supported by the development of a comprehensive Learning Resource Package tailored to the Nepalese context, which includes the PEN-Plus clinical protocol, facilitator’s guides, learner’s guides and a mid-level healthcare provider orientation manual, which has been endorsed by MoHP. This also demonstrates the government’s commitment to institutionalising the model. This programme has invested in digital learning platforms to promote continuous professional development, remote learning and broader reach. This blended model improves training reach and flexibility, particularly in remote and resource-limited areas. So far, the National Health Training Centre has trained 63 medical officers from PEN-Plus districts in PEN-Plus protocol, 13 as they play a vital role in identifying severe NCD cases and referring them for early detection and timely management. In parallel, clinical experts from referral and tertiary hospitals serve as mentors, offering ongoing oversight and quality assurance while also building a health professional network across care tiers. This dual approach strengthens referral and counter-referral systems, bringing tertiary-level expertise closer to communities and bridging the gap between peripheral and higher-level care. To enhance cardiac diagnostics, PEN-Plus organised a 14-day echocardiography training, enabling doctors to screen for RHD, CHD and other cardiac conditions. So far, 14 doctors from six PEN-Plus implementation sites have received this training, equipping them to detect cardiac abnormalities early and facilitate timely management. In May 2025, 39 mid-level healthcare providers (health assistants, staff nurses, certified medical assistants, auxiliary nurse midwives and auxiliary health workers) working at District Hospital Bajhang were oriented using the PEN-Plus orientation manual. 31 Following this pilot, the orientation is now planned for gradual scale-up in other PEN-Plus districts with the aim of strengthening understanding of severe NCDs and PEN-Plus among providers working at all basic healthcare settings, as they are the first contact point for patients, acting as critical links between rural populations and the formal health system. Equipping them to identify, refer and support patients improves community-level awareness and access to services. Social behavioural change Community awareness and behavioural change are essential components of PEN-Plus, enabling early diagnosis, improved treatment adherence and stigma reduction. 23 Given the stigma around severe NCDs and low public awareness, strategic communication is vital to mobilise communities, empower patients and foster care-seeking behaviour. 24 32 PEN-Plus has launched a series of targeted social and behavioural change communication (SBCC) interventions in collaboration with local government bodies, civil society and health professionals. These efforts aim to reach both patients and the broader public through culturally relevant, context-specific messaging and tools. A key strategy has been co-creation workshops involving patients, families and providers, ensuring messages reflect patients’ experiences and local beliefs. The programme also developed a dedicated logo to brand severe NCD care in Nepal, boosting visibility and recognition. Animated characters and visual storytelling are integrated into information, education and communication materials to engage audiences across literacy levels and age groups. SBCC activities are embedded into clinical and community platforms, including patient education sessions, outreach and media engagement. By integrating communication strategies into service delivery, PEN-Plus helps build informed, empowered communities and increases demand for equitable NCD care. Equipment, infrastructure and supply chain management Quality care requires reliable diagnostics and a functional supply chain. 30 To ensure uninterrupted service delivery, PEN-Plus has supported the equipping of hospitals with essential diagnostic and treatment technologies, critical for managing complex NCDs. These include echocardiography machines, arterial blood gas analysers, high-performance liquid chromatography machines, defibrillators, ECG machines, HbA1c analysers, home-based glucometers and spirometers. The provision of these devices has enabled hospitals to conduct timely and accurate diagnoses and monitoring of patients. The programme also strengthened blood bank facilities in Bardiya by providing component separators (critical for packed cell volume preparation) to prevent fluid overload in patients requiring repeated transfusions. To reduce stock-outs, the programme enhanced forecasting and procurement systems and advocated for essential medicines like insulin and hydroxyurea to be included in government benefit packages. In 2024, the Health Insurance Board updated its benefit package to include hydroxyurea in the insurance package. 33 Together, these enhancements have directly contributed to better service quality and clinical outcomes, particularly for populations with limited access to tertiary care. Budget and financing Despite a high NCD burden, Nepal allocated only 4.95% of its national budget (FY 2023/2024) to SDG 3: Good Health and Well-being, 34 35 significantly below the 10% target set by the National Health Sector Strategy. 36 Sustainable financing is essential for long-term success and scalability of the health system, 30 including PEN-Plus. PEN-Plus currently relies heavily on donor funding, highlighting the need for more stable domestic financing to ensure long-term sustainability and national scale-up. Discussions are underway to operate PEN-Plus through a blended funding model, drawing from government contributions, international donors and global health partnerships. However, given Nepal’s constrained fiscal space, further national scale-up of PEN-Plus will require not only sustainable financing but also robust economic evaluations to inform policy decisions. Incorporating cost-effectiveness or cost-utility analyses would help demonstrate value for money and support prioritisation by the Ministries and financial planners. Beyond cost considerations, investing in severe NCD care is essential because these diseases cause serious complications and early death and mainly affect disadvantaged communities. A critical next step involves integrating severe NCD care into Nepal’s National Health Insurance programme, as several essential PEN-Plus components, such as iron chelators and certain insulin formulations, are not currently covered under the health insurance scheme. Patients currently face substantial out-of-pocket (OOP) expenses for diagnostics, medications and treatment, often leading to delayed care and catastrophic health costs. World Bank data from 2022 shows that OOP payments comprise 55.8% of Nepal’s total health expenditure, 37 while the National Health Accounts report 54.2%–57.9% OOP during FY 2018/2019–2019/2020, with a large share attributed to NCD care. 38 Hospitals also report frequent delays in reimbursement from National Health Insurance, even though the provided services are included in the benefit package, which disrupts medicine availability and laboratory services and results in patients having to pay OOP or depend on PEN-Plus for reimbursement. To address this, advocacy is underway to create a dedicated financing pool for severe NCDs under the National Health Insurance, covering essential drugs, diagnostics, surgical interventions and follow-up care. This would significantly enhance financial protection and access for rural and underserved groups. Further alignment with existing social health protection schemes like Bipanna Nagrik Kosh (Impoverished Citizens’ Fund) 39 offers additional opportunities for strengthening financial protection for patients. This initiative already provides up to NPR 100 000 for poor patients with cardiovascular disease, cancer, renal failure, SCD and neurological conditions. 39 The government also fully subsidises congenital heart surgeries for children under 15 and RHD surgeries at designated centres. Integrating these schemes under a single-door financing policy could minimise duplication and optimise resource use. 40 41 Embedding PEN-Plus into national financing frameworks to ensure provisions for recurrent funding of clinics, infrastructure, workforce and supply chains for severe NCD care will be essential to institutionalise severe NCD care as a permanent health service. Health information system and data management A robust health information system is essential for the effective management of the healthcare system, 30 including severe NCDs. It enables real-time tracking of patient outcomes, service utilisation and programme performance. PEN-Plus has prioritised the development of a comprehensive digital data framework to support evidence-based planning and decision-making. Standardised data collection tools are being implemented across all PEN-Plus sites, ensuring consistency in clinical documentation, patient follow-up and reporting. Efforts are underway to integrate these data streams into Nepal’s existing Health Management Information System, allowing for national-level tracking of severe NCD trends and enabling resource optimisation. To improve care continuity and data accuracy, PEN-Plus is also advocating for the adoption of electronic medical records in peripheral hospitals. Transitioning from paper-based systems will enhance clinical efficiency, reduce errors and facilitate data aggregation. Where digital access is limited, mobile and offline-compatible platforms are being explored to ensure inclusion in remote areas. By embedding digital innovations within routine care, PEN-Plus aims to strengthen Nepal’s capacity to deliver responsive, accountable and scalable services for patients with severe NCDs. Social support and financial assistance Addressing social determinants of health is central to PEN-Plus, particularly for marginalised and low-income populations. Many patients with severe NCDs face substantial barriers to care, including direct healthcare costs, lack of information about entitlements and unaffordable travel or accommodation expenses. 42 Non-medical costs, such as expenses for nutritional supplements, travel costs to reach tertiary centres and income loss, can further drive families into catastrophic health expenditures. To mitigate these challenges, PEN-Plus has introduced a range of social protection measures to reduce the financial burden and improve equitable access to care. 14 The programme ensures that essential services, including diagnostic tests, medications (such as insulin and iron chelators) and home glucometers, are provided free of charge to eligible patients. Surgical care costs for disadvantaged groups, who are identified through a ward-level recommendation letter as per local government social protection procedures, are partially or fully subsidised through donor support. The programme also facilitates patients’ enrolment in the National Health Insurance Scheme and covers premiums for those unable to afford them to promote long-term financial security and continuity of care. Currently, this has been done through financial support from donor agencies, but the programme is continuously advocating for the strengthening of insurance mechanisms for sustainability. In Nepal, while some NCD services are officially provided free of charge in government hospitals, 43 44 many vulnerable individuals remain unaware of these entitlements or are unable to afford transportation costs to access them. 42 Recognising this barrier to accessing care, especially in remote regions, PEN-Plus introduced targeted support for travel and accommodation, ensuring that both patients and caregivers can reach peripheral and referral hospitals without financial hardship. So far, 18 patients from PEN-Plus sites have received such support to undergo life-saving cardiac surgery at tertiary hospitals. These cases underscore the programme’s life-saving impact, which would have been lost due to the inability to afford transportation, even though tertiary services are free. Beyond medical care, PEN-Plus takes a holistic approach by addressing the broader social determinants of health. The programme provides targeted nutritional support, such as eggs, fortified foods and individualised nutrition counselling for children with conditions such as T1DM and SCD, who face a high risk of undernutrition and dietary inadequacy. Educational assistance is also offered to children from economically disadvantaged households, identified through ward recommendations and, when needed, household socioeconomic assessments conducted by the PEN-Plus team. Support includes essential school materials such as school bags, copies, pens, pencils and books, along with school-based awareness activities to reduce stigma and support regular attendance. Furthermore, PEN-Plus acknowledges the emotional burden of living with chronic illness by offering counselling services, peer support groups and safe spaces for engagement between patients and caregivers. By integrating clinical, psychosocial and socioeconomic support, PEN-Plus promotes equity and ensures access to life-saving care for all, regardless of socioeconomic status. Future perspective and policy implications Looking ahead, the long-term success of PEN-Plus in Nepal depends on its strategic integration across all levels of the health system. A key priority is its institutionalisation within national and provincial NCD programmes, supported by clear implementation and monitoring indicators. As early-onset NCDs rise, Nepal’s decentralised model through PEN-Plus offers a practical blueprint for equitable care delivery. Without adequate district-level capacity, equity gaps will widen, and tertiary systems will remain overburdened. Strengthening peripheral hospitals as first referral points, with functional counter-referral systems, can establish an integrated and balanced care pathway. Equally important is the role of primary healthcare facilities, which serve as the first point of contact in the community and ensure timely linkage to PEN-Plus services. A strong primary health centre–district–tertiary referral chain is essential to reduce overload on higher-level hospitals and maintain continuity of care for severe NCDs. Expanding specialised services to historically underserved peripheral hospitals is challenging, especially where such care has never existed. However, Nepal’s early PEN-Plus experience suggests that coordinated government action, strategic investment and disciplined implementation can support scalability and sustainability. The MoHP has demonstrated commitment by prioritising PEN-Plus within national policies, signalling movement beyond time-bound projects. Embedding PEN-Plus into national policy instruments and ministry budgeting frameworks is the next critical step to secure sustained financing and government ownership. Effective decentralisation of comprehensive severe NCD care in low-resource settings requires integrated teams, early diagnosis, appropriate treatment, consistent medicine supply chains and robust patient retention. 45 Nepal’s National Health Insurance Scheme already supports NCD care by covering key diagnostics and medicines and reducing OOP expenditures. 29 It also promotes regular check-ups and early detection for high-risk groups. 29 46 However, significant gaps remain, including the exclusion of essential lifesaving medications such as rapid-acting insulin and iron chelators. Strategic reforms are needed to expand the benefits package, ensure sustainable reimbursement to providers and align with PEN-Plus protocol. Closing these gaps through insurance expansion and policy change is vital for sustainability. 47 Nepal’s experience suggests that decentralising complex care to peripheral hospitals is feasible with modest investment, strong leadership and equity-focused planning. However, in the absence of a full economic evaluation, the broader population-level health impact of PEN-Plus cannot yet be conclusively demonstrated. Nepal’s phased, district-based approach offers lessons for LMICs facing similar challenges like limited tertiary access, early-onset NCDs and underserved rural populations. While Nepal’s experience may not be universally generalisable due to variations in governance and financing systems, several components remain transferable, including service integration within peripheral hospitals, standardised protocols, public and private collaboration and linkage of clinical care with social protection. Countries with decentralised systems may find these insights particularly relevant, though contextual adaptation will be essential. PEN-Plus demonstrates a viable model for inclusive NCD care in settings with constrained resources, both regionally and globally. Despite its promise, PEN-Plus has limitations that should guide future action. Scalability remains challenged by funding constraints and workforce shortages, particularly in remote and mountainous regions where geography limits equitable access. Reliance on donor funding for social protection measures, such as free medications, diagnostics and insurance premium support, raises concerns about financial sustainability without formal inclusion in national financing frameworks. Future evaluations should examine long-term clinical outcomes, care continuity, treatment adherence and cost-effectiveness of decentralising severe NCD services. Implementation research is also needed to assess performance indicators, patient experiences, financial protection outcomes and system-level effects using mixed-methods approaches. These considerations highlight the need for ongoing evaluation, stronger system capacity and expanded qualitative insights to guide the scale-up and institutionalisation of the PEN-Plus model in Nepal and beyond. Conclusion Nepal’s PEN-Plus initiative demonstrates that high-quality, specialised NCD care can be delivered at the district level in low-resource settings. By integrating clinical services with social protection, workforce development and policy alignment, it offers a scalable model for managing severe, early-onset NCDs. Its success highlights the importance of decentralisation, government ownership and strategic financing to ensure equitable health access. As Southeast Asia and other LMICs face similar challenges, Nepal’s experience provides a model for sustainable, inclusive and resilient NCD care systems. It underscores the need for comprehensive, people-centred policies that address not only medical needs but also the social needs necessary for holistic care. Footnotes Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Handling editor: Mark G Shrime Patient consent for publication: Not applicable. Ethics approval: Not applicable. Provenance and peer review: Not commissioned; externally peer reviewed. Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. References 1. World Health Organization Noncommunicable diseases. 2024. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases Available. 2. Li J, Pandian V, Davidson PM, et al. Burden and attributable risk factors of non-communicable diseases and subtypes in 204 countries and territories, 1990–2021: a systematic analysis for the global burden of disease study 2021. Int J Surg. 2025;111:2385–97. doi: 10.1097/JS9.0000000000002260. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 3. UNICEF Non-communicable diseases. behaviours that lead to disease often emerge during childhood and adolescence. 2025. https://www.unicef.org/health/non-communicable-diseases Available. 4. World Health Organization . World Health Organization Regional Office for Africa; 2022. PEN-plus–a regional strategy to address severe noncommunicable diseases at first-level referral health facilities. [ Google Scholar ] 5. Adhikari B, Pandey AR, Lamichhane B, et al. Readiness of health facilities to provide services related to non-communicable diseases in Nepal: evidence from nationally representative Nepal Health Facility Survey 2021. BMJ Open. 2023;13 doi: 10.1136/bmjopen-2023-072673. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 6. World Health Organization . WHO South-East Asia, Nepal; 2022. Nepal implements program to strengthen noncommunicable disease services through capacity building of health workers. https://www.who.int/nepal/news/detail/14-12-2022-nepal-implements-program-to-strengthen-noncommunicable-disease-services-through-capacity-building-of-health-workers Available. [ Google Scholar ] 7. Dhimal M, Bista B, Bhattarai S, et al. Kathmandu: Nepal Health Research Council; 2020. Noncommunicable Disease Risk Factors: STEPS Survey Nepal 2019. [ Google Scholar ] 8. Nepal health research council . Government of Nepal: Government of Nepal, NHRC, and KIOCH; 2023. Assessment of non-communicable diseases and injuries among children in selected tertiary level hospitals in Nepal. [ Google Scholar ] 9. World Health Organization . World Health Organization; 2010. Package of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings. [ Google Scholar ] 10. Epidemiology and Disease Control Division Package of essential non-communicable disease (PEN) intervention at primary health service setting: Ministry of Health and Population. https://edcd.gov.np/uploads/resource/5c39743267983.pdf Available. 11. Gyawali B, Khanal P, Mishra SR, et al. Building Strong Primary Health Care to Tackle the Growing Burden of Non-Communicable Diseases in Nepal. Glob Health Action. 2020;13:1788262. doi: 10.1080/16549716.2020.1788262. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 12. Department of health services . Teku, Kathmandu, Nepal: 2024. Ministry of health and population (MOPH): Annual health report 2079/80. [ Google Scholar ] 13. Department of Health Services . Department of Health Services: Ministry of Health and Population; 2025. Annual health report 2080/81; p. 106. [ Google Scholar ] 14. Kathmandu Institute of Child Health PEN-plus project 2021. 2025. https://kioch.org.np/projects/pen-plus-project Available. 15. Adler AJ, Wroe EB, Atzori A, et al. Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries. BMJ Open. 2024;14 doi: 10.1136/bmjopen-2023-074182. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 16. Boudreaux C, Barango P, Adler A, et al. Addressing severe chronic NCDs across Africa: measuring demand for the Package of Essential Non-communicable Disease Interventions-Plus (PEN-Plus) Health Policy Plan. 2022;37:452–60. doi: 10.1093/heapol/czab142. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 17. NCDI Poverty Network Integrated Chronic Care for People Living with Severe NCDs in Impoverished Rural Areas. 2025. https://www.ncdipoverty.org/penplus-1 Available. 18. Epidemiology and Disease Control Division Non-communicable disease & mental health section department of health services government of Nepal. [11-May-2025]. https://edcd.gov.np/section/ncd-and-mental-health-section Available. Accessed. 19. UNICEF Nepal . UNICEF; 2023. [11-May-2025]. A silent threat: battling the rising tide of NCDS in Nepal. https://www.unicef.org/nepal/stories/silent-threat-battling-rising-tide-ncds-nepal Available. Accessed. [ Google Scholar ] 20. NCDI Poverty Network Network Aligns with the Ministry of Health and PEN-Plus Partners in Nepal. [11-May-2025]. https://www.ncdipoverty.org/blog/2023/10/30/network-team-aligns-with-partners-in-nepal Available. Accessed. 21. Poudel A. The Kathmandu Post; 2023. PEN-plus project to be piloted in four more district hospitals. [ Google Scholar ] 22. Government of Nepal . Ministry of Health and Population; 2020. Public health service regulation 2020. [ Google Scholar ] 23. Bukhman G, Mocumbi A, Wroe E, et al. The PEN-Plus Partnership: addressing severe chronic non-communicable diseases among the poorest billion. Lancet Diabetes Endocrinol. 2023;11:384–6. doi: 10.1016/S2213-8587(23)00118-3. [ DOI ] [ PubMed ] [ Google Scholar ] 24. Government of Nepal Multi-sectoral action plan for prevention and control of non-communicable diseases 2021-2025. 2021 25. Government of Nepal National Health Policy 2074 Ministry of Health and Population. 2019 https://dohs.gov.np/wp-content/uploads/2014/04/NHP-2074_policy-01.pdf Available. 26. National Planning Commission . Kathmandu, Nepal: Government of Nepal, National Planning Commission; 2020. The fifteenth plan (fiscal year 2019/20 – 2023/24) https://npc.gov.np/images/category/15th_plan_English_Version.pdf Available. [ Google Scholar ] 27. Ministry of Health and Population . Kathmandu: Ministry of Health and Population; 2022. Nepal health sector strategic plan 2023-2030. [ Google Scholar ] 28. Ministry of Health and Population . Government of Nepal; 2019. Basic health service package 2018. [ Google Scholar ] 29. Health Insurance Board . Teku, Kathmandu: Government of Nepal; 2022. Annual report fiscal year 2021/22. [ Google Scholar ] 30. World Health Organization Everybody's business: strengthening health systems to improve health outcomes: WHO's framework for action. Everybody's business: strengthening health systems to improve health outcomes: WHO's framework for action. 2007 31. Epidemiology and Disease Control Division PEN-Plus Orientation Manual: EDCD, KIOCH, UNICEF. 2025 https://kioch.org.np/almacenamiento/2025/06/PEN-Plus-Orientation-Manual-May-16-2025.pdf Available. 32. Paudel S, Chalise A, Khatri D, et al. Nepal’s mental health system from public health perspective: a thematic synthesis based on health system building blocks. Lancet Reg Health Southeast Asia. 2025;36:100588. doi: 10.1016/j.lansea.2025.100588. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 33. Health Insurance Board Details and rates of the services included under the package services, 2081. 2024 34. Ministry of Finance Red book with a detailed budget for the fiscal year 2080–81 (2023–24) 2024 35. Ministry of Finance Government of Nepal, Budget Speech of Fiscal Year 2023/24: Presented to the Joint Session of the Federal Parliament. 2023 36. Federal Ministry of Health and Population, BEK/NHSSP . Federal Ministry of Health and Population and British Embassy Kathmandu/Nepal Health Sector Support Programme; 2022. Health sector budget analysis: first five years of federalism. [ Google Scholar ] 37. World Bank Out-of-pocket expenditure as a share of total health expenditure (% of current health expenditure) 2025. https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS?locations=NP Available. 38. Ministry of Health and Population . Kathmandu: Ministry of Health and Population; 2023. Nepal national health accounts 2018/19 -2019/20. [ Google Scholar ] 39. Ministry of Health and Population Program implementation guidelines for the medical treatment of deprived citizens: government of Nepal. 2023 40. Government of Nepal . Policy planning and monitoring division. Kathmandu: Ministry of Health and Population, World Bank, WHO, GIZ; 2019. Situation analysis of health financing in Nepal. [ Google Scholar ] 41. Poudel S, Parajuli A, Paudel S. Social Health Insurance a Key for Universal Health Coverage in Nepal. JKAHS. 2023;6 doi: 10.61814/jkahs.v6i2.819. [ DOI ] [ Google Scholar ] 42. Mali S, Rhodes EC, Nakarmi CS, et al. Barriers and facilitators to patient utilization of noncommunicable disease services in primary healthcare facilities in Nepal: a qualitative study. BMC Health Serv Res. 2025;25:863. doi: 10.1186/s12913-025-13050-8. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 43. Government of Nepal. Nepal Law Commission The Public Health Service Act, 2075 (2018) 2018 44. Shrestha A, Maharjan R, Karmacharya BM, et al. Health system gaps in cardiovascular disease prevention and management in Nepal. BMC Health Serv Res. 2021;21:655. doi: 10.1186/s12913-021-06681-0. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 45. Boudreaux C, Wroe EB, Thapa A, et al. Organization of services for severe chronic Noncommunicable diseases at first-level hospitals in nine lower-income countries: Results from a Baseline assessment of PEN-Plus initiation. PLOS Glob Public Health. 2025;5:e0004552. doi: 10.1371/journal.pgph.0004552. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 46. Poudel S, Parajuli A, Duwadi N, et al. Social health insurance, family support, and chronic diseases as determinants of health service utilization among senior citizens in rural Nepal. BMC Public Health. 2025;25:1512. doi: 10.1186/s12889-025-22693-5. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 47. Gupta N, Mocumbi A, Arwal SH, et al. Prioritizing Health-Sector Interventions for Noncommunicable Diseases and Injuries in Low- and Lower-Middle Income Countries: National NCDI Poverty Commissions. Glob Health Sci Pract. 2021;9:626–39. doi: 10.9745/GHSP-D-21-00035. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Data Availability Statement All data relevant to the study are included in the article or uploaded as supplementary information. 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